Authorization Agreement for Pre-Authorized Payments
Name :
*
Church or individual
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GCFA #
For churches only
I (we) hereby authorize the West Ohio Annual Conference of the United Methodist Church (Conference) to initiate debit entries to my (our) bank account indicated below and the depository named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account for:
Health Insurance Premium Payments
2nd of the month
15th of the month
Pension Payments
2nd of the month
15th of the month
I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. This authority is to remain in full force and effect until the Conference has received written notification of its termination in such time and in such manner as to afford the Conference and Financial Institution a reasonable opportunity to act on it.
Start Month
*
Account Type
Checking
Savings
Bank Name
Account #
*
second set of 10-12 numbers on a check
Routing #
*
first set of 9 numbers on a check
Please upload a voided check
Browse Files
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Name of authorized account signer
*
First Name
Last Name
Signature of authorized account signer
*
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